The 10 best states for physicians in 2020

Like most things in life, choosing where to practice medicine comes with pros, cons and trade-offs. Some physicians want to practice in a big city, others a one-stoplight town — and everything in between.

But besides personal and lifestyle reasons, there are some states that are better for physicians than others in terms of finances, competition and other criteria.

In the 2020 Best States to Practice project, our partner publication Physicians Practice compiled some publicly available data to provide a perspective on what states can be best described as “physician friendly.”

For our analysis, our editors ranked the states based on 2019 data covering five categories:

Tax climate (state collections per capita)

Physicians Practice obtained the data from publicly available sources.

The list should not be taken as ranking which states are better than others. It simply provides physicians with some objective data they can use when making their career decisions.

See the entire Best States to Practice at Physicians Practice’s website.

Articles

We analyzed objective data to determine the best states for doctors


The 10 best states for physicians

Data has shown that diabetes increases a person’s susceptibility to severe COVID-19, making it especially important for those with diabetes to limit their potential exposure to the virus.

The COVID-19 health crisis has underscored the importance of having technology that helps medical professionals easily identify their patients with diabetes and verify their adherence with testing and office visits.

“When New York became a COVID-19 hotspot, our providers understood that if patients failed to monitor and manage their blood glucose levels, miss routine follow-up touch points, or otherwise not receive the care they needed, they could be at increased risk of not just long-term complications, such as heart and kidney disease and vision and nerve problems, but short-term, potentially life-threating issues such as severe low blood glucose levels or diabetic ketoacidosis,” says Jill Brodsky, M.D., FAAP, associate medical director, chair of the department of pediatrics, and pediatric endocrinologist at CareMount Medical in Poughkeepsie, New York.

Since the start of the pandemic, COVID-19 has presented both challenges and opportunities for diabetes management and technology.

Varun Goyal, CEO of Illuminate Health, notes that, on average, individuals with diabetes spend 66 minutes per day on self-care tasks, and since the pandemic, access to their medications and health care providers has become tricky.

“Thankfully, technology has become that enabler of care guidance for patients at home, while providing connectivity to their clinicians,” Goyal says. “Given that patients are holding off on health care services, there are risks of disease progression and even potential hospitalization if patients do not take care of themselves.”

One of the most important technologies in recent years is the Continuous Glucose Monitoring (CGM) device, which eliminates the need for finger-prick glucose testing. CGMs continue to evolve, becoming less invasive, more accurate and easier for patients to use.

“CGM use provides real-time information to patients and their caregivers about blood sugar levels and provides alerts and alarms to the patient to immediately inform them when their blood sugar leaves the target range established by their provider,” Brodsky says. “Some CGMs enable patients to scan a reading device across the sensor to get readings, while others provide continuous readings via a Bluetooth connection between their CGM and their cellphone or smartwatch.”

Additionally, through integration with insulin pump therapy, CGMs can change the rate of insulin flow to minimize high blood glucose readings and reduce episodes of hypoglycemia.

All of these data can be shared directly with the patient’s provider at any time, virtually or in the office. This is particularly useful for patients who are uncomfortable venturing out during the pandemic.

Most health care experts agree that practices need an option for virtual visits for patients who don’t necessarily require an in-person visit but still need care from their provider.

Reza Mizani, M.D., FASN, founder and CEO of South Texas Renal Care Group in San Antonio, notes recent publications have shown that patients with Type 2 diabetes have 4 times the risk of death from COVID-19 and much longer hospital stays than those without the condition.

Therefore, it is crucial that patients with diabetes achieve HbA1C levels less than 6.5%. It also is important that patients prevent possible exposure to COVID-19 by avoiding high-traffic health care facilities such as hospitals and doctor’s offices.

“The use of telehealth during this era has been extremely beneficial in keeping our patients safe and continuing care,” Mizani says. “With [the Health Insurance Portability and Accountability Act] relaxing their rules and regulations, physicians have been able to reach their patients by utilizing Facetime and Google Duo, among other popular video communication platforms. I strongly believe in the use of this technology and recommend telemedicine stays in place with the appropriate insurance reimbursement so that physicians and patients can continue to interact in a more modern and accessible way.”

Chris McCann, co-founder and CEO of Current Health, which provides a remote patient monitoring platform powered by artificial intelligence and cleared by the Food and Drug Administration, notes managing diabetes can mean regular visits to the doctor, as well as unforeseen hospitalizations. Having the ability to replace these appointments with video visits can minimize patients’ risk of exposure while helping them maintain diabetic control through virtual engagement such as diet assessment, changes to medication or insulin titration.

Current Health’s remote monitoring platform integrates with Dexcom’s G6 continuous glucose monitor to provide physicians with the broadest picture of patient health possible.

“Remote monitoring provides real-time insight into patient health, allowing clinicians to spot patient deterioration early and intervene to avoid serious health issues,” he says. “For patients with diabetes, this could mean avoiding serious hospitalization events such as diabetic ketoacidosis or hypoglycemia by noticing early signs such a pulse and respiratory rate changes and derangement in glucose.”

Through clinical monitoring of these vital signs, providers can identify if a patient is not being adherent, or if their current therapy is not working, and act before a patient ends up in the hospital.

Kathleen Prendergast, M.D., chair of endocrinology and medical director of the University of Maryland Center for Diabetes and Endocrinology at the University of Maryland Baltimore Washington Medical Center, notes diabetes visits lend themselves well to the telehealth platform.

“Our practice transitioned to 100% telehealth during the shutdown in Maryland, and care for this population of patients was able to be continued with limited interruption,” she says. “Many patients hope that telehealth will remain an option even after the threat from the pandemic subsides. Telehealth does, however, work best if the patient has a smartphone so that a video call can be completed. Phone calls are utilized in cases when the patient does not have access to the video component and, while useful, often are not as fruitful as a video visit.”

Many patients with diabetes already were using technology on a day-to-day basis before the pandemic. Prendergast notes the use of insulin pumps and continuous glucose monitors, as well as “smart” glucometers or insulin pens, has risen significantly over the last several years.

“These devices can be uploaded to the cloud or emailed to the providers so that a great deal of data can be stored,” Prendergast says. “During the telehealth visit, this can easily be accessed and reviewed with the patient. These tech items have been demonstrated to improve diabetes control and increase patient satisfaction with their diabetes care.”

Teresa McArthur, senior vice president of clinical services for Cecelia Health, a virtual diabetes and chronic disease management startup, notes expanded digital and telehealth access has opened doors to reengage in care for individuals with diabetes who faced access barriers, such as the inability to take time off work for in-person appointments, transportation issues, or time associated with travel and appointment waits.

“With remote appointments, patients who may not have been within driving distance of an endocrinologist can now be prescribed continuous glucose monitoring, which has been proven to help patients manage their blood sugar levels,” she says. “Covid-19 made telehealth more than a critical channel; it proved telehealth’s value as the critical channel for ongoing chronic care management.”

Because patients respond differently to different communication channels, physicians should consider a variety of technologies to connect with patients. In some cases, phone calls may be ideal. Other patients may respond best to secure texting, email or secure messaging via a patient portal, which supports secure communication between providers and patients and allows for prescription renewal requests and online scheduling.

“The portal is a useful tool that is convenient for patients and allows us to connect with patients who may have gaps in care,” Brodsky says. “We also use Salesforce as part of our patient engagement strategy, which gives us an efficient mechanism to communicate with patients sooner versus later.”

McArthur says smartphones provide tremendous opportunity to better link physicians with their patients, but a number of regulatory, access and adoption barriers have prevented the smartphone from becoming the gold standard in physician-patient communications.

“We’ve found in our populations that it’s still advisable that physicians adopt an omnichannel approach that incorporates video, audio and digital options when looking to foster dialogue with patients,” she says. “Given the hyper-individualized nature of managing diabetes, there is no one silver bullet technology or service that has shown complete effectiveness at addressing barriers to diabetes self-management. So it’s crucial that people in remote monitoring programs have access to the spectrum of management resources, rather than being limited by a payer or program to a single solution.”

That means the most effective remote management approach must incorporate a blend of human touch via expert clinical coaching and familiarity with various technologies so patients understand how their devices work and care teams can respond to any “red flags” identified either by the participant or by an abnormal lab value transmitted by their device.

“The future integration of doctor’s offices with the increased connectivity of CGM devices such as Dexcom, FreeStyle Libre, among others, will greatly enhance patient adherence moving forward,” Mizani says.

Innovative technology helps patients adhere to their treatment and stay safe during the COVID-19 pandemic.

Frontiers in diabetes patient management

It is hard to overstate the importance of some decisions. In the life of a physician, the choice of where to practice certainly falls into that category.

“Location can impact your daily practice, as well as your career trajectory and quality of life outside of work,” says Wade A. Brosius, D.O., a primary care physician at Spring-Ford Family Practice in Royersford, Pennsylvania, and acute care for elders medical director for Tandigm Health. “Choosing the right type of practice––large or small, independent or system-owned, single- or multispecialty––can also go a long way toward overall job satisfaction.”

The best time for making this choice varies. Sometime during the residency seems to be the best option for most physicians, with earlier starts allowing more time for exploration. But waiting until the third year is also acceptable if the delay is not too long, according to Travis Singleton, executive vice president of marketing and sales at Merritt Hawkins. “Given the dampening effect of COVID-19 on the job market, it’s better to job hunt earlier in the year and not wait until you are a few months out,” he says.

Regardless of timing, selecting where to practice merits careful investigation. In making your decision, consider these tips.

Don’t rule out the independent and/or small group route

Although large health care systems have much to offer, other possibilities may be worth considering. Independent or smaller groups may offer increased reward potential, more autonomy, less bureaucracy, greater flexibility and an ability to limit payors, says Reuben Elovitz, M.D., CEO of Private Health Dallas in Texas.

Of course, there can also be a downside, with the potential for increased financial risk, reduced negotiating power for contracts, reduced benefits, or fewer referrals. But for some physicians, smaller is simply a better match.

It may be tempting to stick with the familiar, but that can be a mistake.

“In terms of geography, think outside the box,” Singleton says. “Don’t be bound by preconceptions.” Rather than limit your choices to a few areas you know, consider the qualities and options you want in a location, whether that means good schools, cultural and recreational amenities, or something as basic as safety.

Clive Fields, M.D., chief medical officer and cofounder of VillageMD in Houston, Texas, believes that identifying a work environment that’s a good cultural and clinical fit is essential. “Working with like-minded physicians is critical to long-term career satisfaction,” he says. If your clinical interest is in wellness and prevention, a practice with large skilled nursing or hospital obligations would likely not be a good fit. If you have a young family and specific family interests, look for organizations and locations that will give you both the time and opportunity to engage in those activities.

Unless you are totally on your own, any location decision should include family considerations.

“If the location is not the right fit for you and your family, that may not be the best practice for you,” says Gary Price, M.D., president of The Physicians Foundation. “I know of physicians who had the opportunity to practice their dream job in their dream city, but because their spouses were simply not happy there, they had to relocate.” In fact, that almost happened in Price’s case. He found a location and practice which seemed ideal, but his wife quickly realized that the area was almost devoid of young families. They looked elsewhere, finding an alternative that proved to be a better fit.

If the goal is starting a private practice rather than joining an existing one, facilities planning should commence up to two years in advance. When looking for space to lease, the search should begin 12 to 14 months ahead of the planned opening, according to Justin Brasell, executive vice president at Transwestern, a national commercial real estate firm. When looking to build a new property, physicians should start the site selection process 18 to 24 months before opening. This allows enough time for finding the site, negotiating the sale of the land, closing on the land, designing the facility, and constructing a new building.

Andrew H. Rosenthal, M.D., medical director of plastic surgery at Modernizing Medicine in South Florida, advises supplementing research with personal insights. “Talk to those that came before as you are finishing residency,” he says. “Ask what the landscape and journey looked like for them.” Talking to people in a community where you might want to live can also be helpful, but keep in mind that their agendas can color the information offered. Insightful sources of information may include CEOs of hospitals in the area. “They are often more than willing to talk and will give you a good picture of the landscape,” Rosenthal says.

The American Medical Association (AMA) recommends creating a checklist for investigating and acting on practice choices. Such a list might include lifestyle factors, available practice options, steps in becoming practice-ready and key components of employment contracts.

It is hard to overstate the importance of some decisions. In the life of a physician, the choice of where to practice certainly falls into that category. Here's how to make the best choice for you.

7 tips for deciding where to practice medicine

Transitional care management (TCM) services, which help patients transition from inpatient care to the community setting, are critical for preventing readmissions and keeping patients on a smooth track to recovery. The services, denoted by CPT codes 99495 and 99496, also are lucrative for practices, paying up to approximately $248 for 30 days of service.

However, there’s one big challenge: Independent physicians aren’t usually notified when patients are admitted to and discharged from the hospital. This makes it difficult to meet TCM billing requirements that specify physicians must contact patients within two business days of discharge and conduct a follow-up visit within seven or 14 days post-discharge, depending on the patient’s medical complexity, says Samuel Leroy Church, M.D., CPC, family medicine physician in Hiawassee, Georgia, and an American Academy of Family Physicians adviser for theAmerican Medical Association’s Current Procedural Terminology editorial panel.

The good news is that information between hospitals and physicians can flow more freely thanks to a new CMS Condition of Participation (CoP). CoPs are the health and safety standards that health care organizations must meet to participate in Medicare and Medicaid programs. The new CoP, which goes into effect May 1, 2021, requires hospitals (i.e., acute care hospitals, cancer hospitals, children’s hospitals, rehabilitation hospitals, long-term care hospitals and transplant programs) to send real-time e-notifications of any admissions, discharges or transfers (ADT) to applicable post-acute care providers with established care relationships who need that information for treatment, care coordination or quality-improvement activities.

E-notifications must include, at a minimum, the patient’s name, treating practitioner’s name and sending institution’s name. CMS created this requirement as part of the Interoperability and Patient Access Final Rule (85 FR 25510) to significantly accelerate information sharing between hospitals and other providers across the care continuum.

“If hospitals routinely send us their information, it does eliminate a lot of steps and busywork on our part,” says Gregory Steinmetz, M.D., a family medicine physician in Warwick, Rhode Island. “It will be better for patient care, and primary care practices will have more incentives and support to provide TCM services.”

“If practices don’t already perform and bill TCM, they may want to consider it in light of these new changes,” says Peter S. Tippett, M.D., Ph.D., founder and CEO of careMESH, a technology platform that improves the quality and reach of ADT data from hospitals to physician practices. “If they already do, they may want to revisit the efficiency of their existing service line and explore ways to partner with local hospitals trying to satisfy the new CoP requirement.”

Experts provide these tips to create a successful TCM offering:

Determine how the practice will receive ADT data

The new CMS CoP is a big step forward because it means independent practices may start to receive this data automatically. However, in order for this process to occur seamlessly, patients will need to identify their primary care physician at the time of hospital registration, says Kim Huey, CPC, CCS-P, independent coding and reimbursement consultant in Alabaster, Alabama. “This is a challenge because patients don’t seem to attach themselves to a primary care physician. Instead, they go to urgent care,” she says. “Care has become very fragmented.”

To address this challenge, physicians need to focus on building relationships with their patients, Huey says. Patients need to view their primary care as a one-stop shop for the majority of their health care needs. They also need to understand the importance of identifying their primary care physician when they are admitted to the hospital or seek care outside of the practice, she adds.

Another option for accessing ADT data is through a health information exchange (HIE). One drawback? Someone from the practice must log onto the HIE portal to manually review the ADT data. In addition, practices must frequently update their patient panel to ensure the HIE has the accurate list of patients to attribute to the practice, Tippett says.

Another challenge with HIEs is that they are regional. If a practice belongs to one HIE and a patient is admitted to a hospital that is part of a different HIE, the practice won’t have access to ADT data.

HIEs aren’t necessarily a timely source of information either, says Cheryl Mongillo, MBA, administrative director at a family medicine practice in Wilmington, Delaware. Some hospitals don’t push their data to the HIE until physicians sign the discharge summary, she says. “It could take a week for this to happen, which means it’s beyond the window for billing TCM,” she adds.

Finally, ADT data exchange through HIEs only works if patients actually consent to participate in the HIE itself.

Practices that belong to an Accountable Care Organization (ACO) may have more luck receiving timely ADT feeds. “What we pay to belong to our ACO has been worth it simply because it enables us to bill TCM,” Mongillo says. Her practice’s ACO sends ADT feeds for attributed patients as defined by their shared-savings contracts with Medicare, Medicaid and commercial payers. Then a medical assistant logs on to the ACO portal to check live data feeds and contact patients as necessary.

However, there are pitfalls even when receiving ADT feeds from an ACO. For example, when patients are discharged to a skilled nursing facility or inpatient rehabilitation facility, the ACO doesn’t have access to the facility name, making it difficult to track discharges from those settings, Mongillo says.

“Are there other patients who fall through the cracks? Absolutely because they may not be attributed to us, or we may not have a shared-savings contract with their insurer,” she says. However, there are other workarounds. For example, when patients come in for preoperative clearance, staff insert a flag in the EHR for the date of the surgery so they can follow up with the patient.

Mongillo also strives to build relationships with local hospitals so they provide ADT information via phone. “All hospitals have discharge planners,” she says. “I tell them, ‘Let us work with you to prevent readmissions. We can help schedule that follow-up visit to help the patient stay out of the hospital.’”

Provide TCM via telehealth or home visits, when warranted

If patients are unable to travel post-discharge, or if they are uncomfortable coming into the office during the pandemic, telehealth or home visits may be options. Giving patients the choice is paramount in terms of obtaining buy-in for TCM service, Mongillo says. “The more patients feel like they’re involved, the more willing they are to comply,” she adds.

Although Medicare covers TCM rendered via telehealth, commercial payer coverage may vary, says Huey, adding it’s best to contact each payer to determine its policy. Note that Medicare and most other payers will also require modifier -95.

Identify other patient care needs and revenue opportunities

Chronic care management (CCM) is a big one. While TCM focuses on the 30 days post-discharge, CCM focuses on the patient’s health indefinitely, Church says. “It’s all part of an ongoing movement to centralize care in the primary care setting,” he adds.

Note that effective January 1, 2020, with the calendar year 2020 Physician Fee Schedule Final Rule, CMS relaxed its restrictions on concurrent use of TCM and CCM as long as the work is distinct, meaning both services address two different diagnoses. Previously, practices couldn’t bill TCM and CCM during the same 30-day period.

“This was an important step in reducing administrative worries for practices trying to run an ongoing CCM program aimed at long-term reduction of hospitalization and emergency room visits,” Church says. “You don’t necessarily need to abandon the CCM work in order to provide the TCM. That has been a big help.”

For example, a patient admitted to the hospital due to pneumonia can receive TCM upon discharge as well as CCM related to their diabetes and ulcers.

An annual wellness visit or advanced care planning are other billable services from which patients could also benefit at the time of TCM, Huey says.

Physicians also can separately bill an office visit at the time of TCM as long as documentation supports each code, Huey says. For example, a patient receiving TCM post-discharge after a hip replacement develops a sore throat and needs to be seen. Practices can bill the TCM and an E/M code during the same 30 days, Mongillo says. “Many practices haven’t done this,” she adds. “This means they’ve been missing opportunities for revenue as well as closing care gaps.”

Physicians may be tempted to document TCM sparsely (“The patient is recovering well. I reconciled their medications and referred them for physical therapy,” for example). However, if the patient is readmitted or dies within 30 days, practices are obligated to change the visit from TCM to an office visit and resubmit a corrected claim, Huey says. That’s because TCM is technically for 30 days of service, she adds.

Huey recommends physicians document the TCM visit as they would any other office visit, just in case the visit does need to be rebilled. What diagnoses, if any, did the physician take into consideration when developing an ongoing treatment plan? This may include diagnoses in addition to the condition for which the patient was hospitalized. What is the assessment and plan?

“Even though all of those details may not be necessary to get the TCM paid, it’s going to show the complexity — everything you need to consider when treating the patient,” Huey says. This translates to more accurate E/M codes, particularly in 2021 when codes will be driven by medical decision-making or time.

If physicians aren’t already billing for TCM, they should strongly consider it as the industry moves toward a value-based care model, Church says. “TCM is not just about payment for providers or saving money for the system,” he adds. “It’s about patient care. Patient care is better. Quality of life is better. Patient engagement is better. Ultimately, care outcomes are better.”

Transitional care management

As the technological landscape evolves, so does the world of health care. Using smartphone apps, doctors can utilize technology to improve their understanding of their patients’ health.

While there are myriad apps available in digital storefronts hosted by Apple, Google and Amazon, it can be difficult to choose an effective app that also keeps patient health data safe.

The intelligence of smartphones in the exam room

Bradley Crotty, M.D., MPH, chief digital engagement officer and internist at Froedtert & Medical College of Wisconsin, sees the use of medical apps as a step along the road to making health care less of a transactional relationship between patient and physician.

“People come into the doctor’s office maybe two times a year, maybe four times a year, but most of the time they are managing their medical conditions along with their lives at home with their family,” he says. “They are left to take that 15 minutes or 30 minutes of time with a doctor and put together a plan, and then follow through with that plan at their home, at work or on the job.”

While these plans often consist of taking medication, they also may include changes in behaviors or routines that are more difficult for patients to engage with when they are not under their physician’s supervision.

Crotty says that smartphone medical apps and other digital tools can be a way for physicians to further patients’ health goals outside of the exam room by addressing behavior such as diet changes and exercise.

, there were 165,000 mobile health apps available in Apple and Google digital storefronts. In the four years since that study was conducted, that number has only grown. According to IQVIA, over 200 health apps are added each day.

With a seemingly endless supply of possibilities to choose from, choosing one for patients can be daunting.

Crotty says that when creating a framework for deciding which apps to fold into a practice, keep in mind what goals there are for the app. Some apps are aimed solely at the patient, while some share information directly with the physician without the patient’s involvement. Complicating matters more, Crotty says some apps are a hybrid of the two.

It is also wise to assess whether any research has been done on the app, as many have not been approved by the U.S. Food and Drug Administration, according to Crotty.

study suggests that clinicians and patients be included in the process of reviewing which apps to use. It found weak correlations between the consumer rating available on digital storefronts, their usability and their clinical utility.

Natasha Fuksina, M.D., practices internal and obesity medicine in Newark, New Jersey. She says that an often-overlooked aspect of choosing an app for patients to use is whether it is compatible with the practice’s EHR system.

An app may be perfect for a patient\. “But how will that actually be implemented and integrated into the EHR?” she asks.

Another facet in deciding which apps is right for patients is cost. Apps that modify behavior and keep the patient in closer contact with their physician can ultimately save health care costs for both the patients and insurers, Crotty says.

Crotty believes that as these apps become more commonly used in a care setting, contracts with insurers likely will be negotiated to make the apps more economically viable as part of value-based care.

Apps may come with initial purchase costs or in-app-purchases, which can be a burden for patients, so that cost should also be taken into account when choosing which app patients should use.

study is the apps’ crisis management. The authors found that the majority of apps they studied at the time were not equipped to properly deal with a situation where the data patients input indicate a health crisis.

Any app that tracks vital health information should be equipped with the ability to alert the doctor if a catastrophic health event is detected.

While these apps have many positive aspects, including improved accountability and ease of use, one of the biggest concerns regarding their use in the health care setting is the question of privacy.

study found that many of the apps reviewed were using unsecure data transfer methods, such as email and text messages, to pass information between the patient and physician.

Crotty says this is an issue that must be addressed as these apps become more prevalent in the health care space. He also is concerned about the lack of transparency by app developers who are known to sell user data.

He says that doctors should have a discussion with their patients, similar to an informal informed consent, about using these apps. Some of the questions that should be addressed include:

If data are being transferred and reviewed, what are the expectations?

How are the data being stored and how long are the data being kept?

This conversation may be a patient’s best opportunity to receive direct answers to these questions, Crotty says.

Fuksina finds it quite easy to get her patients to engage with apps due to the prevalence of similar technology in the market.

“Many people now own an [Apple Watch] or Fitbit are able to use their phones to download simple apps,” she says. “And even though we do not have, right now, an app [that] integrates with our particular EHR to be able to scale it … it can ensure some patients’ responsibility and improve [adherence] and, in a way, help them be accountable for their own health goals. I’ve been able to inspire and teach them myself on several apps that I believe are very helpful.”

Crotty says to ask all patients what they are doing on their smartphones. It’s likely that they are already using their phones to search for health information on Google. Once that is known, a physician can look for opportunities to build on the what the patients are already using. To encourage patients to take full advantage of these apps, it’s important to get their families involved in keeping the patient accountable. “The patient and family are the least-utilized resource on a health care team,” Crotty says.

Use apps to improve patient outcomes

In the 1930s, physician house calls represented 40 percent of all physician-patient encounters. By 1980, that number had fallen to less than one percent. But the “golden age” of the physician house call has come full circle—albeit in a virtual fashion.

With modern technology, not even the most welcoming office can humanize health care the way a virtual house call can. For years, we’ve assumed that physicians and patients must sit together in the same exam room to develop personal, trust-filled relationships. But COVID-19 has proven that communication technology can create enormously personal connections.

It’s easy to see why patients are eagerly embracing virtual relationships with their physicians as well. Eighty-three percent of Americans say they expect to make telehealth visits after COVID-19 has ended. This number is huge when you consider the fact that just eight percent of patients had ever had a telehealth visit before the pandemic hit. Many organizations put telehealth in place so quickly that they are struggling to live up to patient expectations when it comes to virtual communication. A recent study compared patient attitudes immediately prior to COVID-19 and then again months into the pandemic. It not only found that patients’ desire for digital communication has risen, but that overall patient satisfaction is down.

The good news is that the development of virtual relationships goes way beyond the traditional video or audio-based telehealth visit. In fact, the virtual physician-patient relationship can be built with or without the use of telehealth at all. There are a variety of ways practices can reach out to patients that don’t involve the actual visit. patients virtually.

We all know that most people don’t answer incoming phone calls anymore. What you might be surprised to learn is that 19 percent of people never check their voicemail. Ever. This means that a huge number of those messages left by your staff are going ignored. Texting has become the most preferred way to communicate—and not just for friends and family. Forty-seven percent of patients (and this number is growing every day) want the ability to text back and forth with their provider. Two-way texting is the first step in developing a virtual relationship with patients. Patients are able to shoot off a quick text to ask a question or set up an appointment. You are able to respond quickly and easily.

Did you know that the majority of patients fail to remember the recommendations and treatments their physicians give them? The use of automated calls or emails to remind patients of care instructions helps take care of this problem. At the same time, it lets patients know that you care about them and their health. Not only will this help improve care adherence rates, but it will also boost overall satisfaction levels. Patients feel connected to you and the relationship is strengthened.

Health care organizations should send out regular educational communication in the form of newsletters or emails. Much like the automated care instructions, this information will reinforce the feeling that you care about a patient’s health. This is especially important during times like COVID-19 where patients are feeling confused and worried. During the pandemic, always err on the side of over-communicating rather than under-communicating. In addition to regular newsletters, consider sending targeted educational information to patients who fall into specific categories. For example, you may want to send emails specifically to all of your patients over the age of 65 or those diagnosed with high-risk conditions such as diabetes.

Even automated messages reminding patients of upcoming appointments or overdue bills can deepen a relationship with your patients. The more touchpoints you can leverage to connect will trigger name recognition and remembrance. As a patient sees that you are working to reach out to them, that relationship grows.

We live in a digital world and it is time for health care organizations to take advantage of it. There are opportunities available to connect and communicate with patients that would have been unimaginable just a few years ago. 

Josh Weiner is the CEO of SR Health by Solutionreach. Send your practice management questions to Medec@mjhlifesciences.com.

For years, we’ve assumed that physicians and patients must sit together in the same exam room to develop personal, trust-filled relationships. But COVID-19 has proven that communication technology can create enormously personal connections.

How doctors can humanize virtual care

As scientists endeavor to build biological vaccines for COVID-19, there is increasing recognition that societies must look beyond biological methods alone. This means “digital therapeutics,” are needed to change human behavior and build societal resilience.

In order to successfully combat the virus, we must complement biological vaccines with digital vaccines, a subcategory of digital therapeutics, to inform and educate the population and reinforce behavior.

Digital vaccines are envisioned as evidence-based prevention approaches delivered via smart phones and tablets to encourage positive behavior. They are gamified, digital interventions that draw on principles of neuroscience, psychology, artificial intelligence (AI) and behavioral economics to provide safe and low-risk mechanisms for influencing significant behavior change. The goal is to provide fun, immersive and motivational features within a mobile app to encourage nonaddictive, interactive, game-playing experiences and induce desired changes in behaviors.

This idea of digital health technologies is supported by the Food and Drug Administration (FDA). “In the context of the COVID-19 public health emergency, the use of digital health technologies…has the potential to facilitate social distancing by reducing patient contact with, and proximity to, health care providers, and can ease the burden on hospitals, other health care facilities and health care professionals that are experiencing increased demand due to the COVID-19 public health emergency,” the FDA reported in guidelines issued in April.

Digital vaccines can leverage proven neurocognitive training to change behaviors, reach a broad audience and be deployed widely, quickly and updated frequently. Using these training methods and mobile technologies, digital vaccines are showing promising evidence of changing behavior in pilot randomized controlled studies. Highly interactive video games with animation activities train the brain to improve processing, understanding and memory by stimulating the neurological functioning and the cognitive ability of individuals.

Digital vaccines that are enabled via gamified, mobile applications can be culturally sensitive and customizable to specific regions and contexts. They can entail deep levels of personalization to ensure that vaccines meet the requirements of target audiences from all geographical, social and cultural realms. For example, to develop a COVID-19 digital vaccine that promotes hand hygiene in a specific region in India, researchers are examining the sociological, environmental and regional norms to adapt an existing game for hand-hygiene literacy to include local preferences.

This technology would allow rapid deployment of the digital vaccine, which can learn and adapt based on live and forecasted data. In the case of a rapidly changing virus, we need to approach containment and immunization with agility and precision that exceeds the vectors of infection. AI-driven approaches provide a system of automated learning frameworks, moderated through human intervention and feedback loops, that can stay ahead of an epidemic.

We are in the process of adapting and scaling an existing digital vaccine, conducting randomized field trials and ongoing research and development to gather and analyze evidence of positive behavioral and physiological outcomes. We are working to design, implement and deploy the technology at scale within populations that are at high risk. The key outcomes will be tracking incidence of COVID-19, time factors and transmission rates, as well as uptake of health-hygiene practices.

If the trial is successful, this evidence-based digital vaccine candidate for infectious diseases could be made available for global adoption to help alleviate health challenges caused not only by COVID-19 but also infectious diseases to come.

 is Trustees Professor of Management Science and Healthcare Informatics at the Heinz College of Information Systems and Public Policy at Carnegie Mellon University in Pittsburgh.

How to fight COVID with digital vaccines

“In terms of geography, think outside the box,” Singleton says. “Don’t be bound by preconceptions.” Rather than limit your choices to a few areas you know, consider the qualities and options you want in a location, whether that means good schools, cultural and recreational amenities, or something as basic as safety.


Clive Fields, M.D., chief medical officer and cofounder of VillageMD in Houston, Texas, believes that identifying a work environment that’s a good cultural and clinical fit is essential. “Working with like-minded physicians is critical to long-term career satisfaction,” he says. If your clinical interest is in wellness and prevention, a practice with large skilled nursing or hospital obligations would likely not be a good fit. If you have a young family and specific family interests, look for organizations and locations that will give you both the time and opportunity to engage in those activities.


“If the location is not the right fit for you and your family, that may not be the best practice for you,” says Gary Price, M.D., president of The Physicians Foundation. “I know of physicians who had the opportunity to practice their dream job in their dream city, but because their spouses were simply not happy there, they had to relocate.” In fact, that almost happened in Price’s case. He found a location and practice which seemed ideal, but his wife quickly realized that the area was almost devoid of young families. They looked elsewhere, finding an alternative that proved to be a better fit.


Deciding where to practice medicine requires careful planning if you want a successful career. Here are 7 tips to get you started.

Deciding where  to practice: 7 tips

The COVID-19 pandemic has brought a lot of unknowns into the practice of medicine. Doctors are already dealing with diagnosing and treating people affected by the deadly virus while trying to keep themselves and their staffs safe from infection. But with the threat of infection also comes the threat of 

for not taking the proper precautions against it. Medical Economics spoke with Stephanie Sheps, vice president of claims, Coverys, a medical liability insurance provider, to discuss liability risk in the age of COVID.

(Editor’s note: The following transcript has been edited for clarity and brevity.)

What new liability threats have emerged from COVID-19?

 First, there are the obvious risks that include transmission of COVID, both to patients and to staff. It's a novel issue because we're not fully understanding this virus yet, so things continue to evolve daily. Based on patient and provider awareness and precautionary measures taken to mitigate these risks, I believe that the greater liability actually stems from pandemic-related or contextual realms. And so, pandemic risks are those that do not involve the diagnosis or treatment of COVID-19, or the transmission of it, but are related to the changes in how healthcare is currently being delivered or not delivered. These risks include the denial of services to patients because of lack of capacity, or the availability of PPE, and provider and facilities that delay elective surgeries because of capacity issues, etc. Another significant area of risks stem from the fact that many providers have and continue to defer their primary care visits, their annual checkups of patients, routine screenings like mammograms and colonoscopies, things that we do to manage chronic conditions. And the fact that those are being deferred or if they're being held, are being held virtually, does present some risk. I mean, there's a reason we see our providers in person, they get to put eyes on the patient, they get to take labs, they get to really assess the patient using all of their senses. And so when that is being limited by doing these types of visits through telehealth, I think that could present some greater risk in the future. And just one final note is that on the patient side, many people are making the choice to delay or defer treatment, because they're fearful of going into the doctor's office or a hospital, or they're trying to be a good citizen and think their issue isn't that serious. [They say] other people need the facilities more, I will just hang back. And because they make those decisions, sometimes, we've seen increased risks of heart attacks and strokes that are having greater morbidity and mortality, because people are waiting it out at home. You've even seen some cases of delayed setting of fractures, because people just thought I'll wait this out, it's not that bad. And the longer they wait to deal with those issues, the more morbidity there could be.

 Is following CDC guidelines, as far as safety goes, enough to protect the practice from lawsuits?

 Well, I think it's a good starting place, and of course, would advise everybody to continue to follow those guidelines, but it's not the panacea to prevent claims and suits. In essence, the standard of care is going to come from the region, the whatever the law is the common law, the statutory law in that jurisdiction, that will define the standard of care. Now we're functioning under what we like to think of as a crisis standard of care right now, but only time will tell how things are perceived and adjudicated in the courts. So it’s always a good idea to follow the CDC guidelines. But unfortunately, I can't say that it will be totally preventative of claims.

 Are there common mistakes or oversights that make practices more vulnerable to COVID-related lawsuits?

 I would say yes and no. And the reason I equivocate there is that these are common issues that would have existed before COVID. So the failure to document informed consent or informed refusal of treatment, those are risks that exist, no matter what. Obviously, there are these specific risks that patients will get the disease or transmit the disease to your staff while they're there. But I think to me, the greatest risk right now is that providers are so focused on making sure that they are safe that their patients are safe, and their other staff members are safe from contracting COVID, that they may overlook traditional typical patient safety and risk mitigation efforts.

 Have there been any court cases that offer any insight into how the courts will look at these COVID issues?

 We are not yet really there, as it is a little bit early in the lifecycle of what are potential suits or suits related to COVID. Not many have been filed yet that are very specific to COVID and that aren't just contextual or pandemic-related. But it takes some time for things to wind their way through the court system. There was one decision in the federal district court in New York, that actually remanded a case that was filed in the federal courts extensively, to bring certain allegations that were federal in nature, but it was remanded back to the states so that it wouldn't have the protections of the PREP Act.

 Is there a particular type of practice that might be more vulnerable than another?

 So the obvious answer to that question is long-term care facilities are obviously at heightened risk because they contain a very vulnerable patient population. And there have been numerous incidents and cases of COVID and COVID mortalities in those settings. It’s really any place where patients are in inpatient care, so that could be behavioral health facilities, hospitals, any of those locations have greater risk, because of the density of patients and just the multitude of staff and interactions that the patients are having.

 Is there any state or region where COVID-related actions are more prevalent than another?

 So it's a little too soon to tell where things are more prevalent, because as I said, not a lot has been filed in terms of COVID-specific lawsuits. But I suspect that we will see more case activity in states that don't have specific immunity for COVID-related countermeasures. So some of those are legislated, some of those are by executive order, but those states will probably see more activity. Also we’ll probably see more activity in states without tort reform, that is states that do not have caps on non-economic damages. And finally, I believe that states that have had limited or no specific guidance on public health and safety measures like wearing masks, I think just by logical extension, those states may see more claims activity related to COVID, because those states are more likely to have more patients who contract COVID. And everything, just like the virus, continues to spread exponentially in

the states that have passed legislation that helps protect businesses from COVID-related lawsuits.

 The states that have passed legislation that helps protect businesses from COVID-related lawsuits—do these laws help medical practices as well?

 Absolutely, they do. And the one that provides the broadest protection is the federal extension of the PREP Act, which happened back in March of this year. And what the PREP Act does is it provides immunity to certain individuals, in this case, medical or health care providers, for countermeasures taken to deal with health crises during this period of time. Many states have taken the initiative to invoke their own state-related liability protections and some of those are even stronger and broader and more encompassing, to protect health care providers, than the PREP Act itself. So there really are good protections out there for health care providers. But like anything else, there are ways around them.

 What do practices need to do to minimize their risk from COVID-related legal action?

 So one of the things that we have been advocating quite a bit is to first of all, not forget about our traditional risk management and clinical risk management practices, but also to employ tactical risk management. Those are things that we need to do today in the anticipation that we will have to defend claims in the future. For tactical risk management, we bucket our recommendations into timeline, record keeping, and memory. We recommend that health care providers, their practices, as well as facilities, that they keep a very detailed timeline of everything that has transpired related to the pandemic. And the reason we recommend this is that most of these cases should they exist, will be heard by a jury three to four years from now. And if we are lucky, as a society, this will be a distant memory, but people won't have that eye, they won't have the impulse and the ideas when they're sitting in a jury, to remember what this time was like in our history. We need to be proactive about keeping these records. We want to memorialize on a timeline, the date, there's a long list of dates, but the date that the first case of COVID was diagnosed at your facility or in your practice, the date testing became available, the dates of any declaration of a state of emergency in your jurisdiction.

We want to know the dates where maybe PPE was limited, or there were issues with ventilators, if we didn't have enough ventilators, for patients in the inpatient setting. Any dates relating to staffing shortages, furloughs, or reallocations, a lot of staff in the hospital or long-term care setting are having to figure out new parts of their facility, new jobs within the facility to maintain the patient population and their employment. All of these dates are critical to being able to set the stage and not have to go back three to four years from now to figure out and put the pieces together of what has transpired.

In terms of record keeping, it's very important that we have all of the documents that are related to some of those dates on the timeline. So that could be documents related to when we ordered PPE and that PPE was not available. Make sure that we've got pure documentation, including the purchase orders, or letters from suppliers saying, we don't have masks available for the next six months, whatever those things may be, where your supplies were diverted, or anything that backs up the situation that has been occurring while you're trying to deliver patient care. It's also important to have records of patient logs in terms of when they had visitors and when they left, or dates when the visitation may have been limited or flatly refused during that period of time.

Any meetings regarding staffing or documents that give us a record of training and orientation of staff if they work allocated within the facility are very helpful documentation, along with any furloughs and leaves of absence for providers who were concerned about contracting the disease are very important. Another thing that we recommend is maintaining a floor plan for how isolation is going to take place or did take place for patients that were COVID positive or suspected COVID positive, evidence of any in-service training for your staff, related specifically to the virus from this period of time. And any evidence of reviews of quality assurance or compliance would be a very helpful thing to maintain in terms of your record documentation. All of these things contribute to preserving memory. But then we also want to memorialize the people who really are your subject matter experts within your facility, about everything related to this crisis. So keep a record today of who was working in your HR department, and who is going to be your person with the most knowledge. If a deposition is taken during litigation later on, we want to not have to think back to who was working in 2020, we want to have that recorded. And that person may want to keep notes of what it was like to work during that period of time. And one final recommendation that we've made is, if possible, to have a video of the day in the life of your facility or your practice during this period of time. I think it is so important as memories fade, to get a context and to have a living example of how we functioned during this pandemic. Because hopefully, it will be but a distant memory a few years from now. And it will be important to be able to bring a jury back to this period in time and to really illustrate what it was like to deliver health care during a pandemic.

 It sounds like if a practice or facility has not done these steps, it would behoove them to start to go back now and compile all these documents, rather than waiting until a legal action occurs.

 Absolutely, that is the whole strategy behind the tactical risk management is that it's not too late to start today. Just pull all of this together and trust me, but you will think thank me for the recommendation. It will be so much harder to put this together in the future. And it will benefit the defense of any cases so greatly to have all of this information in one place, starting with your timeline, then connecting that to all of your records and documentation that support that timeline, and then finally preserving the memories of the actual people who are in charge of those decisions, and of creating the protocols and following state federal guidelines with respect to the pandemic.

 Does the typical malpractice insurance policy cover COVID-related claims?

 It's a little bit of a tricky question. Typically, yes, a medical professional liability policy covers what we call professional services, which is insurance company lingo for rendering medical care, essentially. So the policy would cover that. The exceptions come from the fact that most policies exclude willful or intentional conduct and many also exclude gross negligence. And unfortunately, because of the exceptions to most state immunities and federal immunity under the PREP Act, those exceptions are for willful misconduct or gross negligence, resulting in patient injury. The plaintiff's attorneys are pleading the cases with those allegations to get around the immunity and the policy may not cover. Because of that, most carriers are going to look at things very fact specifically and look at it very critically with the allegation. And if there is an item of medical negligence that has been alleged, they will almost always defend the provider or facility under a reservation of rights, which essentially says, if this proves to be medical negligence and it is not been stopped by the immunity laws, we will cover this. If this truly becomes gross negligence or willful misconduct, then we will not be able to indemnify. So that's hopefully a helpful answer to many about how these policies apply. What we're going to do, though, is our very best to when we do defend a provider or facility for one of these allegations is to get it dismissed as soon as possible, so it is just not something lingering over you or something that we have to worry about indemnifying in the future.

What you need to know to protect your practice.

Medical Economics December 2020